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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7011 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � ! <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- Date Issued _L-2,Z-2,6 <br /> l (Complete In Triplicate) <br /> Applicgtion' nis' hereby.made to the San Joaquin Local health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin. <br /> County Ordinance No. 1862- and the Rules and Regulations of the San Joaquin Local Health District. <br />'4 ,JOB ADDRESS/LOCATION ,_�s Lao,_" CENSUS TRACT <br /> Owner's Name' - Phone " <br /> Address city.' <br /> Contractor's Name License # UW Phone <br /> ;TYPE OF WORK (Check): NEW WELL DEEPER '/7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/7 PUMP REPLACEMENT <br /> Other / / <br /> �IDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT rPRIVY <br /> Ir . SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E. ' PROPERTY LINE - PRIVATE DOMESTIC WELL' ' PUBLIC DOMESTIC WELL <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial.. Cable Tool Dia. of Well Excavation, "v <br /> Domestic/private Drilled Dia. of Well Casing �} <br /> Domestic/public Driven Gauge of Casing �! <br /> Irrigation .. Gravel• Pack- Depth of Grout Seal <br /> i Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> CPUMP INSTALLATION: - Contractor <br /> Type of Pump H.P. <br /> , PUMP REPLACEMENT: , / State Work Done ` <br /> PUMP' REPAIR: 4/ / State Work Donee y. <br /> 'RES1RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 11 hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> , and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> :kafter completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> iELL DRILLERS REPORT of the well. and notify, them before putting.the.-well- in.use.... The above <br /> nformation is true to the,best of my knowledge and belief. ' I WILL CALL ,FOR A'GROUT INSPECTION, <br /> PRIOR TO,,GROUTING 'AND A FINAL INSPECTION. <br /> I FSIGNED _ _ .� �._ � - TITLE r <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ;PHASE I _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I NAL INSPECTI <br /> INSPECTION BY DATE INSPECTION.]BY DATE <br /> _ 1' -2 l <br /> �_H 1426.'^.:, Rwu�r 1--7G. <br />